Cifal jeju workshop application with attachments green energy and sustinable city planning 01 19

Workshop Application Form ○ Title: ○ Date: ○ Place:

"Workshop on Green Energy and Sustainable City Planning" 21~24 March 2016 (Mon-Thu) International Convention Center, Jeju-do, Korea

v Application form and attachments should be scanned and submitted by email, to UNITAR CIFAL Jeju/JITC at cifaljeju.env@gmail.com by 5 February 2016 (Friday) (with "March 2016 Workshop Application" in the subject line) or fax them to +82-64738-4626.

Applicant name (Please type your name in capital letters as written in your passport.)

Title

Mr/Ms/Mrs/Dr/Others (please specify)

Surname Middle name First name Position

Gender (M/F)

Date of Birth (yyyy/mm/dd)

Nationality Postal Address (office)

PO box Street City Postcode Country

Contact Information (country code + regional code + phone/fax no.)

E-mail Office phone Mobile phone Fax

Organizational Affiliation (Choose one. Please specify the name of your organization in the space provided.)

Academia Government -national Government – local Government – state International organization (non UN) NGO Other Private sector Regional organization UN/UN system UN/UN system (locally recruited)

Describe your work

Reference

(Please provide the name and address of your supervisor/the head of your organization/government)

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Name

Position

Contact details

How did you learn about the event?

(Choose all that apply.)

By mailed or faxed announcement By email By social network (Facebook, Twitter, etc.)

By word of mouth By local press Other

Workshop will take place in English as standard. Please indicate your ability to work and communicate in English Have you participated in a previous CIFAL event?

Native speaker Excellent Good Need support Official English test score, if any If yes, please specify Yes (

)

No (

)

Questionnaire Needs assessment for “Workshop on Green Energy and Sustainable City Planning” ※ Please describe as much detail as possible below in your own words (maximum 300 words) ※ All the answers will be thoroughly read during the selection process.

1. Please give a summary of your area of work and which of the workshop themes this relates to

2. Please describe your motivation to attend the workshop and how the workshop matches your professional development needs

3. Please describe the expected impact of your participation to the workshop on your personal and professional development, including your ability to work on a national, regional or local level

4. Please indicate how you will disseminate the outcome of the workshop and the new knowledge, skills and network you have acquired

5. Please state the three key challenges for your government/agency/institution in implementing strategies and policies for green energy and sustainable city planning

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Case Study Description Guidelines l l l l l

Case study title: Name: Organization: City/Country: Description: (maximum 2 pages in a MS Word) −

City profile (basic facts about your city)

−

SWOT analysis of policy effectiveness of applicants’ government/organization in green energy and sustainable city planning (※ SWOT: strength, weakness, opportunity and threat)

−

National/local plan in green energy and sustainable city planning

−

Government/organization engagement in national, regional or international activities to address the issue of green energy and sustainable city planning

−

Government/organization initiated activities to promote effective green energy policies and sustainable city planning strategies

−

Programs to raise awareness

−

Key challenges

※ Successful applicants will be required to submit a completed case study presentation in MS Power Point (no more than 15 slides) by 26 February 2016 (Friday).

※ Please attach:

① Case study description ② Letter of nomination ③ Letter of commitment ④ Acknowledgement, waiver and release of liability ⑤ Consent to collection, usage and disclosure of personal information ⑥ Curriculum vitae (CV) Ms. BAE Sunwoo, Program Officer UNITAR CIFAL Jeju/JITC 227-24, Jungmungwangwang-ro, Seogwipo-si, Jeju-do, Republic of Korea Phone: +82-64-735-6581 Fax: +82-64-738-4626 Email: cifaljeju.env@gmail.com

※ For general information please contact:

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LETTER OF NOMINATION

Organization name:

_______________________________________

Nominates the following person (name):

_______________________________________

To participate in the UNITAR CIFAL Jeju/JITC workshop, and certifies that: − All information supplied by the nominee is complete and correct; − The nominee has adequate knowledge of the working language of the training program (English); − The nominee, if selected, will participate actively and conscientiously in all the training activities provided by UNITAR CIFAL Jeju/JITC.

Applicant’s immediate supervisor:

(Name) _______________________________________ (Position) _____________________________________ (Office telephone number) ______________________ (E-mail address)________________________________

_____________________________________ Date

_____________________________________ Signature

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LETTER OF COMMITMENT

All parts of the above application form are true and verifiable. If I am selected to participate in the UNITAR CIFAL Jeju/JITC workshop, I will attend all its training activities, actively pursue my project objectives and complete any assignments given related to the training program. I am aware that I have to submit a summary of my case study, and once selected, submit the full case study within the specified dates.

___________________________________ Printed name

___________________________________ Signature

___________________________________ Date

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ACKNOWLEDGEMENT, WAIVER AND RELEASE OF LIABILITY I FULLY ACKNOWLEGE THE ACTIVITY MAY INVOLVE RISKS AND HEREBY ASSUME ALL OF THE RISKS AND RESPONSIBILITIES ASSOCIATED WITH THIS EVENT, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, and actions of other people involved, or because of their possible liability without fault.

I certify that I am physically fit, have sufficiently prepared for participation in this activity, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this activity.

I acknowledge that this Acknowledgement, Waiver and Release of Liability form will be used by the event holders, sponsors, and organizers of the activity in which I may participate, and that it will govern my actions and responsibilities at said activity.

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity.

I understand while participating in this activity, I may be photographed. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by the activity holders, producers, sponsors, and organizers.

The Acknowledgement, Waiver and Release of Liability form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.

I AGREE to the Acknowledgement, Waiver and Release of Liability Statement.

_____________________________________ Applicant name (Please PRINT)

_____________________________________ Applicant signature

_____________________________________ Passport number

_____________________________________ Date

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CONSENT TO COLLECTION, USAGE, AND DISCLOSURE OF PERSONAL INFORMATION CIFAL Jeju/JITC is required to collect personal information of the persons and entities involved in the event. According to the Personal Information Protection Law, CIFAL Jeju/JITC needs your consent to collecting, using and disclosing the following information.

Please read below to confirm the articles and sign the form.

1.

Purposes of collection, usage and disclosure of personal information − To protect the right for learning by verifying authenticity of the provided documents from you − To establish and maintain contact with you − To send you newsletters and other information mailings − To remind you of upcoming appointments and events − To communicate with other persons and entities involved including, by way of example and not limitation, the event holders, sponsors, and organizers of the activity in which you may participate, and that will govern my actions and responsibilities at said activity − To comply with all regulatory and statutory requirements in the case of legal events

2.

Categories of personal information − Name, date of birth, professional and academic background and other personal information stated in the required documents.

3.

Information keeping period − Within five years upon an event ends.

All the information collected from you will be handled responsibly. By signing this Consent to Collection, Usage and Disclosure of Personal Information Form, you have agreed that you have given your consent to your personal information outlined above.

I CERTIFY THAT I HAVE READ THIS DOCUMENT THAT EXPLAINS HOW YOUR ORGANIZATION WILL USE AND PROTECT MY PERSONAL INFORMATION. I AGREE to the Consent to Collection, Usage and Disclosure of Personal Information Statement.

_____________________________________ Applicant name (Please PRINT)

_____________________________________ Applicant signature

_____________________________________ Passport number

_____________________________________ Date

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